A and Part B form the core of Medicare. They provide the coverage that you have if you enroll in the traditional or original Medicare program that has been around since 1966, although many more services have been added since then. Parts A and B are also the basis of your coverage if you’re in a Medicare Advantage health plan, because all those plans must by law cover the same services as the traditional program, although the plans can provide extra benefits if they want to. (I go into detail about the differences between traditional Medicare and Medicare Advantage plans in Chapter 9.)
These two parts of Medicare cover entirely different services, as explained in Chapter 1. But sometimes Parts A and B work in tandem. For example, if you need to go into the hospital, in most cases Part A covers the cost of your room, meals, and nursing care after you’ve met the deductible. But Part B covers the cost of your medical treatment – services provided by surgeons, other doctors, and anesthetists. This division of coverage also applies to staying in a skilled nursing facility for continuing care after leaving the hospital, using home health services, and receiving hospice care.
In the following sections, I describe broad categories of services that Parts A and B pay for.
Necessary medical care
In essence, Medicare covers services that are reasonable or necessary to save life and maintain or improve health. That includes really big-ticket items – such as transplants of the heart and other organs, delicate surgery to repair severe injuries, cancer treatments, and many others – that cost Medicare tens of thousands, and in some cases hundreds of thousands, of dollars. The program also, of course, covers more-routine and less-expensive services, from allergy shots to X-rays.
No doubt about it: Medicare can split hairs. It may cover a service in some circumstances but not others. One glaring example of this discrepancy is that Medicare covers powered wheelchairs (as opposed to the conventional type) only if you need one to get around inside your home but not if you need one just to be mobile outdoors. Medicare may also cover a treatment in some parts of the country but not everywhere. (I go into the difference between national coverage determinations, which cover people in need of them throughout the country, and other coverage determinations that are made regionally, in Chapter 14.) But on the whole, Medicare pays for a vast range of medical services that people need.
Preventive care
Being able to treat a medical problem is good, but dodging it altogether is better! These days, that seems an obvious truth. Yet Medicare has only fairly recently expanded coverage for services that help prevent or stave off some of the diseases that make people very ill and – not coincidentally – cost Medicare mountains of money. Even better: Many of these preventive tests, screenings, and counseling sessions now come free (no co-pays or deductibles) thanks to the 2010 Affordable Care Act. More than 60 million people with Medicare took advantage of these services, at no cost to themselves, during the first three years after they became free on January 1, 2011, according to government reports.
Now take a look at Table 2-1, which shows the range of preventive tests, screenings, and counseling sessions that Medicare covers under Part B and whether they cost you anything. It’s a pretty impressive list!
TABLE 2-1 Preventive Care Services Medicare Covers
Source: Centers for Medicare & Medicaid Services
Note: Services labeled “free” (meaning no co-pay or deductible required) assume that you go to a doctor who accepts Medicare’s payment in full.
Specialized care in certain circumstances
Medicare Part A is usually associated with care within the hospital, of course. But it also covers certain specialized services outside the hospital, most of which focus on nursing. The following sections provide a quick overview.
Care in a skilled nursing facility
Say you’ve been in the hospital and are being discharged but still need more-specialized nursing care than you can receive at home – physical therapy to help you walk again after a hip replacement, speech therapy after a stroke, a continuing need for intravenous fluids, or wound care. Medicare covers this type of ongoing care under Part A, usually at what’s called a skilled nursing facility – most often a nursing home – under certain conditions.
The most important condition for Medicare coverage of care in a skilled nursing facility is that you must have been in the hospital as a formally admitted patient for at least three days. (This three-day rule conceals a hidden pitfall – situations where the hospital places you under “observation” – that you really need to know about; see Chapter 14.) A doctor must order the services that you need from professionals such as registered nurses and qualified physical therapists and speech or hearing pathologists. And the skilled nursing facility you go to must be one that Medicare has approved.
Traditional Medicare covers stays in a skilled nursing facility for up to 100 days in a benefit period. The first 20 days cost you nothing; from day 21 through day 100, you pay a daily co-pay, which goes up slightly every year. (In 2015, the co-pay was $157.50 a day.) Some Medigap supplemental insurance policies cover these co-pays 100 percent. (Head to Chapter 4 for details about Medigap insurance.) If you’re enrolled in a Medicare Advantage health plan, look at your coverage documents or call your plan to find out what it charges for stays in skilled nursing facilities.
Home health care services
These services provide some of the same types of care that you may get in a skilled nursing facility but bring them to you in your own home. They include
❯❯ Skilled nursing care provided on a part-time basis (no more than eight hours a day over a period of 21 days or less) and including services such as injections, feeding through a tube, and changing catheters and wound dressings.
❯❯ Physical, speech, and occupational therapy from professional therapists to help you walk again, overcome problems in talking, or regain the ability to perform everyday tasks, such as feeding and dressing yourself
